29012 APPOCANT TO FILL IN INFORMATION WITHIN RED LINES-,USE BALL POINT PEN ONLY
CITY OF,CUPERTINO BUILDING-ELECTRICAL: - PERMITNO.' f/1 Q 1
BUILDING DIVISION 'r APPLICATIONIPERMIT PLUMBING-MECHANICAL _ ,2 9 O i Z
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: , 'SANITARY NO., APPLICATION SUBMITTAL DATE
12 4) AttA
OWNER'S NAME: PHONE: • C TRACTOR'S NAME: LIC NO ��
'.
N — `Il N/C CONTROL%
{RCHITECT/ENGINEER: LIC NO: ,ADDRESS: - ❑,
CONTACT: PHONE: a-, L. - _ BUILDING PERMIT INFO
V ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEI
❑ ❑ N " ❑
LICENSED CONTRACTORS DECLARATION- QTY ELECTRIC PERMIT FEE
- I hereby affirm that I'am licensed under provisions of CmFvT 9(commencing _ JOBDESCRIPTION
Q=Z with Section 7000)of Divi.' n3 fthe Bual dP f ssians Gnle andity licenses - RESIDENTIAL'
�0 0 PERMIT ISSUANCE
W Poll force add elen /� ❑SFDWL '-El KITCHEN REMODEL
�UZU License Clnss Sam-.Lia# ����01 1' AppL1ANCE5-RESIDENTIAL C1 ADDITION UMBING RE-PIPE
Dote Cartoons
C• ARCHITECT'S DECLARATION ❑MULTI-UNIT LISI'RUCI'URAL
LC0 PANELS .
O Z - I understood my pious shnll be used es Public rewN „s 1 MODIFICATION
s +' UP'102W AMPS: ❑ ❑
INTERIOR - CHIMNEY REPAIR
E�Fq"t�
LicensedP fe med - 201-IOMAMPS IMPROVEMENT
y•_1 OWNER BUILDER DECLARATION - OVER IIIIKIAMPS - []BATH REMODEUREPAIR'❑DEb10LITION
Q I hereby affirin that l am exempt from the Contractors License L for the
Liyy D y U following reason (Seco 7031.5,E d Professions C d Any 'ty county SIGNS ELECTRICAL El OTHER
ta+l W F which requires a permit t construct,t alt p demolish, r repair any structure -
F7Fj0'3
prior to its s ce also requires the applicant for h permit torite a signed statement SPECIAL CIRCU IT/MISC. - v
'j that he licimewdP tt the p lthe Centel Lice o L (Chapter 9
00 oclarrounil vidt Section 9000)of Division 3 mit Bual sa d Probes....arCvJc)m" TEMP,METER OR POLE INST, - COMMERCIAL:
d y m rC that he is exempt therefrom d the bass for Ne alleged exemption.A'y violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X Lc
Section 7031.5 by any appl or for u Perrot subleus the applicant "I penalty of POWER DEVICES
W^rn
Y not more than five Ll FOOD SERVICE
hundred dollars($500). IMPROVEMENT
01os owner ofthepropeny,or myemployees with wvgeaastheirmrlecompensetion, SWIMMING POOL ELBCTRIC j
will do the work,and the strumure is not intendedor+dfeted farcdo(So 044,Business - _ ❑OTHER
and Professions Code:The Contractor's License Law does T y m a owner of OUTLETS-SWITCHES-FIXTURES
a' 'prnpdny who builds or improves income,and who does so wmk himself,t through
It
own employees,provided that such Improvements not intended Wo Bred far NEW RESIDENTIAL ELECfR SQ IT. a
sale.If.however.the building orimpo.owavnt isxal uhinaneyearof compl me"Ine SQ.FT,FLOOR AREA S/SQ.IT.
owner-builder will have the burden of proem e did not build r improve or par-
Palo
ar- - -
paleof ale). - 4 .fns
❑I u exclusively wmmeting with licen ed contro ars to TOTAL: f 4 &
conewe a project(Seb.7(94,IT .fiess and P IIexact'Code)no Contract 's Li-
c so do esntapplymenownerofpropen who hands or improvevthdre t,and QTY. PLUMBING PERMIT FEE B/
who mets for sueh,projacts wi�hac meso dnaed pursuunuo Conti mr's IV
Loo new - OV'28 ggs
lam xmnpt un Seca P mthiv PERMIT ��'Ys e
4I1%l.n,
Owner _Data an ALTER-DRAIN&VENT-WATER(EA) x'NtVALUATION
R S CO PENSATI ARATION - t -"r HuU
1 hereby iffi an+ rpcnt of p6ljury hne`of the following declandens: BACK PLOW PROTECT.DEV1CP.
❑Ih d 'll "cuts ii%N n elf-lneurefor Workers Compen- DRAINS-FLOOR,ROOF,AREA,CONE, STORIES TYPECONSTRULTION
satin spun
provided for by Section,�7g 11 of th lab C de,fur the Performance of the'
workf wilt
which this permit eJ. ° r FIXTURES-PER TRAP
1 he
a and will maintain Workefs Compensation Insurance,as requiree M1y Section
' 3700 of eLabor Code,for the pertannancc of the work for which this permit is iswed.. GAS-EA.SYSTEM-]INC.4 OUTLETS OCCGROUP APN
MyW ComPenmoan�Surance artier and Policy numberurc:
t LotNo.: GAS-EA.SYSTEM-OVER 4(EA) t
CERTIFICATE OF EXEMPTION MOM WORKERX
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR _
r - - - -
(Thin section nand notbecompleN➢ifthe permit is foroochundreddollere($100) BUILDING DIVISION 17ECREASETRAP'
or less) 'k - / PLANCHP.CK PEE '
I c yedify that the any ma aneeo the as to became
for which this permit ' n'Co pen- SEWER-SANITARY STORM EA.200 IT.
shall
not employ y p n in any manner sit as to become subject t ti W k re'Compen _ ENERGY FEE S
,Z smio Laws of California Data - <
WATER HEATER WNP,NT/ELF,CfR
� Applicant - " GRADING FEE'
y' NOTICE TO APPLICANT:IL after making this Cenificate of Exemption,yon should WATER SYSTEM(TREATING '
.r--� become subject o the Worker's Compensation provisions of the Labor Cade,you must SOILS FEE
forthwith comply with such provisions or.this permit shall he deemed revoked. WATER SERVICE
Q
OZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,ET. PAID ,
Ilecoch affirm that the.iso construction lending agency for the perfarmanceof - Date Receipt#
Pis the work for which this permit Is issued(Sec.3097,Civ,C.) _ -
0 U Lender's Name TOTAL
LTa Lende Address T01
I dapfif,that l ha a end this implication d state that the h e' formation s BUILDING FEE
it Val 'covet 1 agree to comply with all city and evict,contracts ad state laws hearing to QTY MECHANICAL PERMIT FEE
U building construction and hereby authorize reprosernalives of this city to enter upon the SEISMIC PEE
abuvemetnloned properly for inspection purposes. PERMITISSUANCE '
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
' liabilities,judgments,costs and expenses which may in any way rcerue against said City 'ALTER OR ADD TO MECH.
in conra
sequence dflha mining ofiais permit, _ _ PLUMBING FEE ,.g
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO I0.W0 CPM)
EG
SOURCE RULATIONS: MECHANICAL FEE
AIR HANDLINGUNIT(OVER 10.000C FM) CANSTRUCTIONTAX
SignaApplicn✓Connarom - ` Date EXHAUST HOOD(W/DUCT HOUSING MITIGATION FEE
HAZARDOUS MATER DISCLOSURE
WIIIthe epplicam.,future buildingoccupum store or handle hazallouc material HEATING UNIT(TO 100,000 BTU) - - - • -
as def red by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety `
Code,Section 25532(ol HEATING UNIT(OVER 100.000 BTU)
❑ye" 7 N I - PAID
VENTILATION FAN(SINGLE RESID)
' Dote RecelPtp
Wrd ther coon future building by the Bt use equipment or devices which ,
emit h d rwm" t . defined by the Bay Area Air Quality Management BOILER-COME(3Hp OR 100,00H BTU)� ,District? TOTAL:
' ❑Yw -` E]No .� .. � BOILER-COMP(OVER IfN1,Of10 BTU) ,.
(have read the h>vuNous materials requiicmena under Chapter h95 of the Cull- AIR CONDITIONER ISSUANCE DATE
fornia Health&Safety Code:Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. •SQ.PT. '
building does Hai conently have a tenant,that it is my responsibility to notify the occupant
ofthe tequnionam s which must he met prior to issuance of a Cenificate of(kcupancy
Owner or authorized agent Date ,TOTAL: ISSUED BY.
OFFICE